‘They deserve very much better,” the distinguished paediatrician Hilary Cass concludes in the final report of her independent review of NHS gender identity services for children and young people. The report details how a vulnerable group has been “exceptionalised” by the NHS and denied the evidence-based healthcare all patients have the right to expect.
Just how badly wrong things went at the gender identity development service (Gids) is evidenced in the fact that Cass felt she had to explicitly state that, while some people argue that clinical care for children should be based on a “social justice” model, “the NHS works in an evidence-based way”. That should never have been up for debate: as the British Medical Journal argued in its editorial on the Cass review last week, it is deeply unethical to provide untested medical interventions for children that lack evidence of benefit, yet are life-altering and come with potentially very significant harms.
But that is exactly what has happened to a growing cohort of children seen by Gids, which has since been shut down. Disproportionately made up of girls and same-sex attracted children, many were put on an irreversible medical pathway without diagnostic criteria. This is despite the fact it can lead to infertility and damage adult sexual functioning; there are also as yet unquantified risks for brain development, bone density and in potentially prolonging gender-related distress that evidence shows may resolve itself naturally in many children.
Because Gids failed to keep adequate data even on the children it was treating in this way, let alone keep track of their outcomes, it is impossible to know the scale of the harm that has been done to them, including how many have now detransitioned or experienced regret. But some young people, like Keira Bell, have bravely spoken out about the painful consequences for them despite being subjected to toxic abuse as a result.
The Cass review sets out an ambitious new way of delivering care for gender-questioning children, grounded in a psychosocial approach that treats them holistically. It recognises that, for many, questioning their gender is not necessarily a sign they will have a fixed trans identity in adulthood, and that children referred to gender services are more likely to be affected by neurodiversity, co-occurring mental health issues, and to have suffered adverse childhood experiences.
They are also much more likely to be same-sex attracted; some clinicians have expressed concern that, instead of helping children process the fact they are gay, gender medicine has encouraged them to instead believe they are born in the wrong body. The review has been broadly welcomed; quite a feat given how contested an area of healthcare this has become. The report will be read by children and young people in distress and their parents, and the evidence it presents will directly contradict the information some have been given by clinicians and campaigners. Cass is to be commended for the measured and compassionate tone she takes in it. But that is not enough: the NHS needs to quickly put in place systems of support for them.
Looking forward, the most important priority for the NHS is delivering the quality of care children deserve yet have been denied by Gids. But there must also be accountability for the managers and clinicians who pursued such unethical practice and caused avoidable harm to young people. For the medical profession as a whole, there is much to reflect on: how did they look the other way as this travesty unfolded? How were adult belief systems allowed to drive healthcare for children, and how were campaigners from outside the NHS and medicine allowed to have so much influence? It is only by learning the lessons that a similar scandal can be avoided again.
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